AOGS
LETTER TO THE EDITOR
Comment on “Longitudinal transvaginal ultrasound evaluation
of cesarean scar niche incidence and depth in the first two years
after single- or double-layer uterotomy closure: a randomized
controlled trial”
Sir,
We read with interest a recent article published by Bamberg et al. (1) that takes up an interesting issue previously pub-lished in the same journal by Kataoka et al. (2) on uterine niche after a cesarean section (CS). These two prospective studies assessed the risk of developing a uterine wall defect at the site of cesarean scar with relation to the surgical closure technique. Both studies assessed the residual myometrium thickness and the depth of the niche as it appears immedi-ately after CS (Kataoka et al.) and on long-term outcomes (24 months in Bamberg et al.) using saline contrast sonohys-terography and a classical sonographic midsagittal view, respectively. These studies are very well conducted and pre-sented but we would share with you some doubts about the method we currently use to evaluate the characteristics of the niche. In fact, the uterine wall defect is known to be associ-ated to gynecological symptoms such as abnormal uterine bleeding, dysmenorrhea and infertility that sometimes requires surgical correction (3). A few years ago, we conducted a prospective longitudinal study comparing two different meth-ods for uterine closure at CS and the long-term risk (24 months) of uterine wall defect that was assessed by ultra-sonography and hysteroscopy (4). Before starting, we carried out a brief pivotal assessment of which sonographic parameter should be used and we realized that the internal defect (niche) is not even at hysteroscopy. In fact, in many cases the depth was not the main cause of clinical symptoms but rather the overall “absent” volume in the internal uterine wall. Statistical analyses demonstrated that a bell-shaped pouch area under the scar could represent best the association between ultrasonography, hysteroscopic assessment, symptoms, and need for surgical correction. In fact, in some cases the defect is shallow but wide, whereas in others it is deep but narrow, as in figure 2 in Bamberg et al. (1).
Certainly, CS is one of the most common surgical operations performed worldwide and its rate has dramatically increased in most developed countries, thus becoming a big concern (5). Yet, the question of which closure technique best avoids symp-tomatic uterine niche remains unanswered, but it seems even more important to find a non-invasive technique to assess the uterine wall defect. The two papers used different sonographic approaches, but we are still wondering if they represent accu-rately the uterine wall defect.
Marco Scioscia1, Piergiorgio Iannone2,* , Danila Morano2,
Giovanni Pontrelli1and Pantaleo Greco2
1Department of Obstetrics and Gynecology, Sacro Cuore Don
Calabria Hospital, Negrar, Verona, Italy, and2Department of Morphology, Surgery and Experimental Medicine, Section of Obstetrics and Gynecology, University of Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Cona, Ferrara, Italy *Corresponding Author: Piergiorgio Iannone E-mail: pg.iannone88@gmail.com DOI: 10.1111/aogs.13278
References
1. Bamberg C, Hinkson L, Dudenhausen JW, Bujak V, Kalache KD, Henrich W. Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single- or double-layer uterotomy closure: a randomized controlled trial. Acta Obstet Gynecol Scand. 2017;96:1484–9.
2. Kataoka S, Tanuma F, Iwaki Y, Iwaki K, Fujii T, Fujimoto T. Comparison of the primary cesarean hysterotomy scars after single- and double-layer interrupted closure. Acta Obstet Gynecol Scand. 2016;95:1352–8.
3. Setubal A, Alves J, Osorio F, Guerra A, Fernandes R, Albornoz J, et al. Treatment for uterine isthmocele, a pouch-like defect at the site of cesarean section scar. J Minim Invasive Gynecol. 2017; Oct 9. pii: S1553-4650(17) 31216-5. https://doi.org/10.1016/j.jmig.2017.09.022. [Epub ahead of print].
4. Ceci O, Cantatore C, Scioscia M, Nardelli C, Ravi M, Vimercati A, et al. Ultrasonographic and hysteroscopic outcomes of uterine scar healing after cesarean section: comparison of two types of single-layer suture. J Obstet Gynaecol Res. 2012;38:1302–7.
5. Indraccolo U, Scutiero G, Matteo M, Indraccolo SR, Greco P. Cesarean section on maternal request: should it be formally prohibited in Italy? Ann Ist Super Sanita. 2015;51:162–6.
